PsychiatryTalk

The Coronavirus Epidemic: Transference and Countertransference Considerations With Remote Therapy

Posted on May 6th, 2020 by Dr. Blumenfield

The Coronavirus Epidemic:  Transference and Countertransference Considerations With Remote Therapy

Michael Blumenfield, M.D.

The Coronavirus epidemic has forced psychotherapists to see patients remotely as we are forced to follow social distancing and in many cases remain quarantined.  I and others have made the case that remote sessions via Zoom, Skype, FaceTime, Doxy, and other systems are not only a safer method to follow during this time of the dangerous epidemic, but under certain circumstances may be more effective than the patient and the therapist sitting across from each other wearing protective masks.  Remote therapy also eliminates travel time for the patient, which often is not only a safety factor during these times, but can be quite valuable as well as convenient for the patient.  I have advocated that as long as there is any health consideration, this method should be continued and have also suggested that when the health crisis has completely passed, therapists and patients may favor continuing the utilization of remote sessions.

However, as we consider making remote sessions the norm, we have to examine how changes in the method of therapy will impact our therapeutic techniques.   Particularly for those of us who are psychoanalysts or psychodynamic therapists, we will need to consider how utilizing remote sessions will impact transference and countertransference.  As we know, “transference” is the phenomena where the patient experiences feelings about the therapist, which originate in the patient’s childhood usually from feelings that one had for primary relationship in childhood most often from emotions related to his or her parents.  Often such feelings are initially identified by feelings that the patient had towards other people in the patient’s life, but frequently get more clearly expressed in the therapeutic relationship.  The transference relationship is usually facilitated by the therapist being a more or less “gray screen” meaning that the patient usually knows very little about the therapist’s personal life or actual personality.  There are exceptions in training programs where the therapist may be a teacher or may have a strong presence on social media.

Now with remote therapy, we have to take into account how the characteristics of remote therapy will influence the development of the transference, the distortion of it or the facilitation of it.  If the therapist chooses to hold the remote video session in a setting which reveals their personal life (i.e., showing personal photos in the background), that certainly could distort or at least influence the transference.  Obviously, this would be more likely to happen if children or other family members or even pets entered into the background of the setting.  The fact that many remote setups actually present much more of a close-up of each participant’s face could influence the emotional experience of the participants.  Also, the clothes that the participants are wearing, personal grooming or lack of it, will all influence the emotional experience of the participants.  Obviously, all the factors which delay or distort transference will also impact countertransference.  In situations where psychoanalytic therapy traditionally has the patient lying on a couch so they will not be influenced by the therapist looking at them, it would seem that a procedure would be developed where both participants after greeting each other would turn off their video setting.

I believe the transference and countertransference will definitely be influenced by remote sessions.  I am confident that all aspects of transference and countertransference will ultimately take place but they no doubt will be influenced by the nature and characteristics of remote therapy.  It will be incumbent that we use thoughtful observations how these may be barriers or distortions in transference and countertransference with this new method.

There is another aspect of how we use our new therapeutic experience to give us insight into the struggle of our patients.  During the current and apparently prolonged health crisis, social contact especially between single people has become limited to remote visits and this fact of life in many cases is limiting and distorting the emotional experience of these relationships and becomes part of the struggle of the patient.  It appears to me that the patients are uncertain how to evaluate their emotional attachments when the contacts are mostly or entirely via remote communication.  By examining the nature of transference in remote therapy, we will provide a method to give the patient insight into this new struggle.

I am sure there will be many papers and presentations which will be examining these issues.  At this time, I would welcome and invite any comments which you can write below.

Psychiatrists and Other Mental Health Therapists Should Continue Remote Sessions with Patients Whenever Possible

Posted on April 22nd, 2020 by Dr. Blumenfield

Michael Blumenfield, M.D. -The Sidney E. Frank Professor Emeritus of Psychiatry and Behavioral Sciences- New York Medical College & in Private Practice in Los Angeles

As the coronavirus epidemic evolves, there is a variable amount of relaxing of requirements for quarantine, wearing masks and gowns, and keeping social distancing.  Particularly for the medical profession, there is more pressure on physicians to allow closer contact for physical examinations, blood drawing, and of course minor and major surgical procedures.  Despite everyone’s best efforts, we all realize that relaxation of these measures will lead to a certain amount of transmission of the virus with subsequent illness and fatalities  (while we hope and pray for this not to happen).

As we progress towards the relaxation of these precautions, psychiatrists and other mental health professionals have been seeing patients via remote (usually video) techniques but also are considering returning to in-person face-to-face visits.  Psychiatrists particularly as part of the medical profession feel a certain obligation to offer their best possible treatment to our patients and to support our colleagues.  Many practitioners who have tried remote therapy believe that remote sessions are inferior to in-person sessions and feel an ethical obligation to resume in-person face-to-face meetings as soon as possible.  In my opinion, this is a serious mistake.  I believe that a careful consideration of all the factors will make a strong case for the maintenance of remote therapy sessions at this time and for this foreseeable future as long as there is the possibility of this deadly epidemic being present and perhaps beyond it.

Obviously, there are exceptional situations such as in consultation- liaison work, emergency rooms, certain crisis situations, drop in clinics, etc., although accommodations to maintain distant contact in these settings may be possible. There are also serious financial considerations to be taken into account, as remote sessions with patients may be reimbursed at a lower rate than face-to-face meetings.  This situation needs to be immediately addressed by our various professional organizations and by the government.

Only a limited proportion of our consulting and waiting rooms can truly allow for a proper social distancing and a maintenance of sanitized furniture for the numerous occupants who will use it.  We are often talking about two people sitting in a closed room probably barely six feet apart for perhaps 45 minutes directly facing each other and talking to each other (granted during psychoanalysis the patient faces away from the therapist while lying on a couch).

Many years ago, I asked an older supervisor (my age now), how he would feel if there could be a clear video connection and whether that could replace an in-person session.  He said (something to the effect) “if you cannot smell the patient, it is not going to be effective treatment.” Our current experience with telepsychiatry has certainly disproved that view.  Also if by some chance one or both of the participants in therapy are wearing a mask, certainly it is much less intimate than a crisp clear face on a large computer screen.  Also when medication needs to be prescribed, that can easily be done by phone, fax, or electronically.

In addition, we should also take into account the travel time (as well as the potential exposure during such travel).  I would estimate that the average patient spends at least a half-hour going one way from their location to my office in Los Angeles plus waiting room time.  That total of about  one hour certainly has value to the patient.  I should also add that everything stated above applies to group therapy.  Maintaining social distance for 6 to 10 people would require a very large room and telepsychiatry methods such as Zoom and other techniques have been proven to be very effective for group meetings.

In conclusion, remote telepsychiatry meetings are very feasible and effective and may very well save the health and lives of both the therapists and patients. There should be consideration of continuing this method of treatment throughout the full run of the coronavirus epidemic and perhaps into the future.  It is also essential that our professional organizations play a very strong role in advocating and encouraging this technique being used by its members and also take a very active role in advocating for equal reimbursement for treatment by these techniques.

      Addendum

I appreciate the thoughtful discussion that this blog has been generating among colleagues. It has led me to write this addendum.

In order for remote tele-therapy to be utilized with maximum effectiveness two conditions must be considered:

  1. The patient and the therapist must be in a comfortable setting. In most cases this would favor using a computer or laptop screen as compared to a handheld i-phone. The participants would most probably be seated in a comfortable chair with or without earphones.
  2.  It is essential that the session be taking place in a confidential manner. This may be difficult to achieve when the participants are at home and in a living or office environment with other people.

To the degree that these two conditions cannot be achieved, this would favor a resumption of in person face to face meetings when there is no longer danger to either patient or therapist of being infected by the deadly virus during travel to the session or during the in-person office visit.

Your comments are welcome below :

The Coronovirus Epidemic: Psychological Considerations with Special Emphasis on Psychological Support for Doctors, Nurses, EMTs, Other First Responders, Including Members of the Media and the Psychological Support Teams Themselves By Michael Blumenfield, M.D.

Posted on March 15th, 2020 by Dr. Blumenfield

The Sidney E. Frank Distinguished Professor Emeritus of Psychiatry and Behavioral Sciences at New York Medical College and currently in private practice in Los Angeles

This presentation originally appeared as a Podcast at PsychiatryTalk.Podbean.com. Dr. Blumenfield can be contacted at MBlumenfield@aol.com

 The Coronavirus: Psychological Considerations with Special Emphasis on Psychological Support for Doctors, Nurses, EMTs, Other First Responders, Including Members of the Media and the Psychological Support Teams Themselves

Hello, I’m Dr. Michael Blumenfield.

Today’s podcast is going to address the psychological issues  of the victims and the potential victims of the coronavirus ,the  people caring for them such as the doctors, nurses, EMTs and other first responders,  the mental health professionals who are involved in supporting these groups and also the members of the various media, print TV, etc., who are also fully exposed to the psychological impact of this epidemic by the nature of their work

Of course every one of us is a potential victim of this life threatening disease. We know that if you are older or have a chronic disease, you are more susceptible and of course we know that transmission occurs by exposure to people who are infected. This knowledge creates conflicts about personal, travel and business decisions, which can be quite agonizing and guilt producing when there is a subsequent loss of business or personal opportunity, or if the decision leads to illness and potential fatalities. The nature of this disease often requires isolation and quarantine of people identified as being exposed to this illness. This situation, of course, can be quite psychologically painful to the person involved as well as to their loved ones. However, modern technology now allows the maintenance of face to face, relatively intimate contact via FaceTime, Skype etc. so people can mitigate some of fear, anxiety and depression of this situation. As will be described below group video meetings can be held vie Zoom

Any situation that changes a person’s usual interactions and travel patterns, increases the possibility that there could be a temporary hiatus in the renewal of their regular medication. This can be important when a person is taking essential medications for diabetes, heart disease and other illnesses. It can also be very important when people with mental symptoms run out of medications in such conditions as schizophrenia, other psychosis, bipolar disorder, anxiety panic and, of course, depression. This situation can be further exacerbated if pharmaceutical companies cannot get essential ingredients from international sources during a worldwide epidemic.  

Mental health professionals in the United States and in many other countries have established very sophisticated techniques for working with patients who have serious medical and even life threatening conditions as well as supporting the medical and   nursing staff caring for them. There is a subspecialty of psychiatry originally known as Consultation-Liaison Psychiatry which as now been subsumed under the particular specialty known as Psychosomatic Medicine.

Of particular note was the work by these specialists in dealing with the AIDS epidemic as well as with burn and trauma patients, cancer, heart disease and other illnesses. It should be noted that during the acute phase of illness, the ideal approach is for the patient or family members to meet individually or sometimes as a couple or family with a mental health professional when there were psychological issues. Sometimes, of course, clergy would be involved. At a later phase there might be referral to some specialized grieving group meetings with others who have lost loved ones.  Mental health professionals trained and experienced in this area of Consultation-Liaison may be particularly appropriate to take a leadership role in the delivery of services, especially  in running any groups.

During the AIDS epidemic there were often particular fears among medical and nursing staff of contracting the disease, especially  before the exact mode of transmission was understood. There were numerous other psychological issues for healthcare workers, victims and families. In situations where there were mass causalities such as after airline crashes and particularly during the World Trade Center 9/11 incident, where there were 1000s of deaths, there were many psychological issues for the families, the surviving victims and also for first responders including the psychological support teams themselves. More recently mass causality events ie. shootings or bombings have raised similar issues, many of which maybe similar to those that we will be seeing during this coronavirus epidemic.  

In the past, particularly prior to 9/11, the usual approach where there were believed to be large numbers of psychological causalities, particularly among the first responders, members of the media  or even among the psychological caregivers themselves, was to use the CISD (Critical Incident Stress Debriefing) approach. This is a technique where a specific group of people ie. doctors, nurses, EMTs,  members of the media or even mental health personnel, would meet in a group with a psychological consultant who would lead them in a discussion of the difficult experiences that they had been through. For example, after a plane crash or a terrible tornado, the police, firemen, EMTs or even reporters would recount the horrible, sights and sounds that they have seen. They might be describing seeing dead children or maimed victims etc. This technique was based a catharsis model which might encourage the participant to “ let it out”, tell about their experiences, nightmares, fantasies and encourage them to discuss how they thought about their own families and personal thoughts.  While such a technique might be helpful in an individual therapy or group therapy treatment dealing with less acute situations such as sharing a struggle with substance abuse, many experts soon realized that having each person recount their own painful horrific experience in this group setting, was usually not helpful.  In fact, to the contrary, such situations were more likely to intensify the anxiety, panic and worry of the other participants of the group. It is a different situation when someone in psychotherapy is reflecting back about a difficult time in his or her life and brings up some painful memory and then gradually lets down their psychological defenses. Or even in a group therapy situation, a person may recall a difficult memory or a current struggle and is getting the support of the other group members, most of whom are not struggling with very similar acute issues. The CISD model, although very well meaning, in my opinion was not effective. In fact, I believe it had the potential to magnify the problems of the other group members and sometimes would breakdown psychological defenses which were helpful at that moment.

This doesn’t meant that there is no value for specific groups to meet under the guidance of a mental health professionals but the approach, in my opinion, should be one that is supportive and affirmative. The group meeting with a leader might address several areas depending on the makeup of the group. There would usually not be any reason to mix the members of the group and. have first responders in the same group as the mental health professionals or clergy or reporters. If group work is being done, they should ideally each be in their own group.

Depending on the particular make-up of the group there are some  potential issues specific groups might address. As I will emphasize in the case of all group meetings and in many cases in individual meetings, because of the potential spread of the Coronavirus, remote face to face techniques should be considered and often will be the preferred form of meetings. Zoom is an excellent system for conferencing with individuals and small groups. Participants do not need have an account. They can see each other. One can also draw on a whiteboard for everyone to see.

Group Meetings Conducted By Mental Health Professionals with Police, Fire and EMTs, Doctors, Nurses and Other Identified Groups Such as Lab Technicians, Coroners Office , etc.  

When possible the groups should be homogeneous . Although they often work side by side, there are individual situations that each group deals with and there is often an esprit de corps that would suggest any such group meeting should be homogenous. As previously stressed, using remote communication methods, such as Zoom,  should be considered because of the nature of the contagious process that is confronting us. However, since these groups often do assemble regularly for assignment and briefings, a portion of that meeting might be assigned for discussion of mental health issues. That could include

1. A general review of symptoms that the people whom they are helping may be experiencing and review of resources available where they can refer any of the  primary victims who need such assistance. The medical providers should be reminded to check to see if their patients have adequate medicine supplies for any mental health or other medical conditions.

2. Stressing the importance of how the caregivers themselves  should be getting adequate sleep and when possible spending time with their families

3- When possible it is valuable to arrange for periodic acknowledgement by superiors or other government officials of the appreciation and value  of the work they are doing. This can be an important morale builder during difficult times Acknowledgment that it s not unusual for people in their position to have symptoms of anxiety, depression, bad dreams, etc. At the same time do not encourage group discussions of individual difficulties or psychological symptoms or problems that members of the group may be having  ( the CISD method).  Most important, would be providing contact information where they any individual can have a confidential meeting  with a  mental health professional..

Group meetings with  Mental Health Professionals Conducted by  Mental Health Professionals  Knowledgeable About Mass Trauma  

Mental Health professionals are usually comfortable working together and it would be quite appropriate to have psychiatrists, psychologists, social workers and mental health nurses all meeting together. As previously stated because of the contagious nature of the disease process, remote group meeting may be necessary or advisable..  If there are people who have experience in the consultation/liaison model of providing support to patients with serious illness and trauma as well as in support of medical and nursing staff, it would be appropriate for them to take a leadership role in this meeting.

1- In the initial meetings of this group, there would be the opportunity to access the mental health professional resources available and identify those with particular applicable  experiences. There would need to be a designation who would run sessions  for particular groups noted above  and who would be available for individual counseling or therapy sessions. Depending on contacts and relationships there could be designated mental health professionals who could reach out and offer support to various leadership people involved in the crisis situation including various agencies and the political leadership.

2- It would be appropriate for a designated experienced mental health professional  person to review  with the group, the nature of the psychological  problems that they are dealing with such as fear, anxiety, separation issues, depression, PTSD, grief, etc  which may be occurring in primary patients and their families. This would likely be something that the mental health professionals  are familiar with but some may not usually work in this area on a day to day basis . This review should include the approach to children and how to answer their concerns and questions in an age related manner. There also should be a discussion of importance of avoiding the CISD approach in a group setting, as previously discussed and encouraging those with significant symptoms to be referred for individual sessions.

3- Remind mental health workers of the importance of recognizing that needed medications for mental health and other conditions may be interrupted and consider if substitute prescribers can be provided and if emergency medication can be provided.

4-As there often is loss of life, it is valuable for the mental health professionals  have an alliance with clergy who can be helpful with acute grieving and general support for many people.

5- During these group meeting with mental health professionals, the importance of their valuable role should be reinforced . At the same time the potential impact on themselves should be acknowledged and there should be a method for any of them to have individual, confidential mental health support.

Group Meetings with Members of the Media Conducted by Mental Health Professionals

During the course of a disaster situation or a public health crisis, members of the media are usually totally involved on a full time basis. They become knowledgeable of the seriousness of the situation and the threat to life, sometimes even more so than the general public . They frequently interview the victims and their families as well as the various first responders and others knowledgeable about the seriousness of the crisis at hand. This group can include reporters, commentators, producers, camera people etc. A group meeting with them where there is an acknowledgement that it is not uncommon for them to have symptoms can be helpful at the same time reminding them that they play an important supportive role in the mental health of their audiences. As previously discussed, the CISD method should be avoided in group meetings but certainly individual confidential  counseling sessions should be available as needed .

I would like to conclude with a brief vignette concerning the important psychological role of the media in supporting the worried public at the time of a major incident

Shortly after the 911 World Trade Center Incident, I was scheduled to do a psychological debriefing with various members of the media and the night before I received a call from a family member. She told me she had a dream that a well known TV news personality was comforting her about this horrific event. In my meeting with the media people I used that story to show them how they provided emotional support as well as the news. At the end of my meeting one of the participants came up to me and told me she was senior producers for the network personality my relative dreamt was comforting her and she was sure he will be very pleased to learn he appeared in a comforting role in her dream in addition to providing the news. My relative was also very surprised and also comforted to hear here he would know about her dream

This presentation was originally presented  on a  podcast by Dr. Blumenfield (PsychiatryTalk.podbean.com). Dr. Blumenfield can be contacted at Mblumenfield@aol.com

Dr. Blumenfield is the Sidney E. Frank Distinguished Professor Emeritus of Psychiatry and Behavioral Sciences at New York Medical College and is currently in private practice in Los Angeles, Californria 

References :

Intervention and Resilience After Mass Trauma, Edited by Michael Blumenfield and Robert J Ursano, Cambridge University Press, 2008

Disaster Psychiatry (Chapter 18) in Psychosomatic Medicine by Michael Blumenfield and Maria Tiamson-Kasab, Wolters Kluwer, Lippincott Williams & Wilkins, 2009

Dr. Blumenfield Now Has New Podcast : PsychiatryTalk.Podbean.com

Posted on July 7th, 2018 by Dr. Blumenfield

I have recently launched a new podcast which can be found at  PsychiatryTalk.podbean.com

There still will be blogs from time to time. Your comments or suggestions are always welcome on the blog or directly to me at MBlumenfield@aol.com

Will You Have Enough Medication at the Time of a Disaster

Posted on October 3rd, 2017 by Dr. Blumenfield

Will you have Enough Medication at the Time of a Disaster?

Empty Medication Bottle

As we see people across the world struggle with unexpected disasters, we might wonder how prepared are we if one should strike where we live? There is a certain amount of preparation that we can do. We can try to live in a safe place. Some people build tornado cellars. One might have supplies to board up the windows. You might have a standby generator. There are now generators that work by solar energy. You can store extra food and water and keep a supply of fuel for your generator and for your car. It’s a good idea to have extra batteries, a hand-cranked flashlight and radio and alternate methods of communicating when the Internet and phone lines might be down. It’s also a good idea to have a first aid kit and supplies. But what about medications??

Would you have a sufficient amount of medication if your hometown were devastated by a catastrophic event and you are isolated for a period of time? What if the local pharmacies weren’t available to renew your medication or if the pharmacy supplies were cut off in an emergency? Suppose you couldn’t reach your doctor for a renewal of your meds? What if the computer systems were down and it cannot be verified that you had insurance for your medications?

Potential Serious Problems If You Run Out of Medication

Since this is a psychiatry blog, let’s start with some psychiatric medications. Certain tranquilizers such as the benzodiazepines can cause withdrawal symptoms if abruptly stopped. This includes Xanax, Ativan, Valium, Klonopin and other drugs especially if these medications are abruptly stopped and especially if you have been using them for a while. In addition, anxiety symptoms including PTSD that these medications may have been treating can be exacerbated at times of a disaster event. If a person who is taking major tranquilizers also known as anitpsychotic medicines such as Seroquel, Abilify, Risperdal, Zyprexa and many others or mood stabilizers such as Lithium, Depakote, Lamictal and many others if withdrawn may be expected to bring about a return of symptoms for which they were being prescribed. This could mean the development of psychotic symptoms with hallucinations, paranoia and delusions or the return of serious mood fluctuations including mania and depression. Similarly, a cessation of a needed antidepressant can cause return of the symptoms of depression and even suicidal ideation although it usually takes a couple of weeks for most of these types of medications to wear off.

Obviously there are similar major problems with a sudden cessation of other classes of drugs. Stopping anti-seizure medications obviously can lead to seizures. Cardiac medications are essential and their removal can lead to very serious problems as can medications for hypertension, diabetes, and various endocrine conditions. The abrupt cessation of medication being prescribed for pain most of which may be opiates can not only bring about the return of pain but some serious withdrawal symptoms. There are many other scenarios which can occur with the unavailability of various medications. And what about birth control pills?

Is it Possible to Have Back-up Medications?

There are also many scenarios where a person may have backup medication and also depending on the situations where that may not be the case. Doctors often prescribed a one-month supply of medications with a certain number of renewals. This might tide you over, but if you were a few days from a needing a renewal when the disaster event occurred, you would have a problem. Sometimes a 90-day supply may be given which probably would be okay unless you were coming near the end of your prescription at the time of the disaster event. Could you reach your doctor or some emergency coverage to get a renewal? Would there be an open pharmacy and will such a pharmacy be supplied with your medication? Also in an emergency or disastrous situation, power and Internet may be down and this could prevent your pharmacy from getting insurance authorization and approval. As you may know, without such approval, many medications can be extremely expensive.

Some people have told me that with each prescription they squirrel away a few pills so they can have a “stash” in case of an emergency. That approach may or may not work and keep in mind in such a situation the medication would most probably need to be rotated so the emergency pills were not outdated.

Could and would a doctor prescribe an extra supply of medication that would allow you to always rotate such pills and keep them current and therefore always have a supply in case of an emergency? Would this be judged as safe for a particular patient? For example, in case of potentially suicidal patients or in case of a situation where a particular medication can be abused, psychiatrists and the other physicians maybe reluctant to prescribe even a 90-day supply. As mentioned previously, medications can be very expensive and insurance companies are sometimes reluctant to authorize large amounts of medication. I also suspect that there may be regulations from state to state and in various different countries that would apply and which also may depend on the type of medication.

Proposed Project For Everyone

I would like to propose a project for the readers of this blog to undertake. Review your own medication. Check with your pharmacy and with your physician to determine if there is a method where you could always have at least a month supply of medication on hand in the event that you could not see your physician and that your pharmacy would not be available or able to fill your prescription at the time of an emergency or disaster. Also be sure to check any insurance coverage that you have whether or not that insurance company would cover the extra prescription and find out what the extra expense would be. Then, please report back to the readers of this blog and myself by putting a comment at the end of the blog. There is no need to publish your name. Perhaps it is time to advocate for some changes in regulations or perhaps we just need to remind people to be prepared.